Abstract
Sequential organ failure assessment (SOFA) score is used as a predictor of outcome
of sepsis in the pediatric intensive care unit. The aim of the study is to determine
the application of SOFA scores as a predictor of outcome in children admitted to the
pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective
observational study. The study took place at the multidisciplinary pediatric intensive
care unit (PICU), tertiary care hospital, South India. The patients included are children,
aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to
a single center PICU in India from November 2017 to November 2019. Data collected
included the demographic, clinical, laboratory, and outcome-related variables. Severity
of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3)
using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff
variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within
24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days
1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock
during the study period. The overall mortality rate was 42 of 240 patients (17.5%).
The majority (59%) required mechanical ventilation, while only 19% required renal
replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with
mortality. All three severity of illness scores were higher among nonsurvivors as
compared with survivors (p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3
(AUC 0.87) demonstrated significantly higher discriminative power for in-hospital
mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]),
and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative
risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions
(vasoactive infusion score), and PICU length of stay were all significantly increased
(p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio
of mortality was elevated at 8.65 (95% CI: 3.48–21.52) on day 1 and 16.77 (95% confidence
interval or CI: 4.7–59.89) on day 3 (p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found
between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1–SF3) and in-hospital mortality
(chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to
50%. Similar association was—observed between ΔSOFA of ≥2 and—longer duration of inotropic
support (p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15–0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both
days 1 and 3, have a greater discriminative power for predicting in-hospital mortality
than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days
1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining
not only mortality risk but also duration of inotropic support as well.
Keywords
SOFA score - PELOD-2 - PRISM III - outcome prediction - septic shock
